Have You Sustained An
Achilles Tendon Rupture?

An Achilles tendon rupture is a significant injury and may require months for recovery. If you've sustained an Achilles rupture there are many questions you need answered, such as: How is a rupture diagnosed? Will I need reconstruction surgery? What can I expect if I have my Achilles surgically repaired? And, how long will recovery take?




Achilles Anatomy

The Achilles tendon is the thick tendon formed by the two muscles of the calf: the gastrocnemius and the soleus. These two muscles function in plantar flexing the ankle. This is the motion that occurs when you rise up on to your toes. The Achilles tendon is located on the back of the ankle and functions in attaching these muscles to the calcaneous or heel bone.


Achilles Tendon


Cause of Tendon Rupture

Because this tendon is used with all walking, running, and jumping activity, injury to the tendon is not uncommon. The most common injury secondary to overuse of the tendon is Achilles Tendonitis. Achilles tendon ruptures can occur after prolonged bouts of tendonitis symptoms. Tendonitis results in stiff and inflexible tendon tissue. In some cases of Achilles tendonitis, micro tears can occur, leading to the weakening of the tissue. Lack of tissue flexibility and tissue weakening (such as tissue weakening associated with cortisone injections) can lead to increased risk of tendon rupture.


achilles tendon rupture



Achilles tendon ruptures generally occur with some type of explosive activity. A common mechanism of injury involves an aggressive push off on the toes such as going for a ball when playing tennis or jumping up for a lay-up while playing basketball. This explosive demand on the tendon is too great with the result being tendon rupture.


Tendon Rupture Signs and Symptoms

When an acute Achilles tendon rupture occurs, the most common symptom is the feeling as if someone kicked you in the back of the leg. The leg simply gives way, often a ‘pop’ is felt, and the ability to push off of the foot is lost. You may still be able to walk and even plantar flex your foot but generally you will walk with a limp. Often swelling will occur immediately.

In some cases the calf muscle will feel like a big ball as the tendon and muscle bunches up. Similar to when a shade is pulled down and then released, when complete rupture occurs the tendon and calf muscle is released and moves up toward the knee.

Diagnosis of an Achilles rupture will be made with both physical exam and a MRI. During the physical exam of your leg, the doctor will perform the Thompson test by squeezing the calf muscle. A normal response is for the foot to plantar flex or the foot to point down. If there is no movement, the test is positive for a tendon rupture.


Click here for an animation of the Thompson Test for Achilles Rupture

If this test is positive, an MRI will often be recommended to confirm the extent of Achilles damage.


Typical Treatment

The decision as to whether or not you will need Achilles tendon surgery will be based in part on the extent of the injury. Other factors include age, activity level, ability to heal, and the quality of the tendon tissue.

A partial tear of the tendon may not require surgery. Rather, an immobilizer will be worn for an extended period of time, allowing the tendon to scar. Frequently the foot will be placed in a plantar flexed or toe down position in order to minimize the stretch on the Achilles. Generally while the tendon heals, you will not be allowed to apply weight on your foot. Healing will take a minimum of six weeks with physical therapy for recovery to follow.

For most, if the tendon is completely ruptured, surgery is the best option. Surgery involves suturing the ends of the Achilles tendon back together.

It is important to note that it is recommend the surgery be performed within a few weeks following injury. Over time the tissue begins to shorten, making it more difficult to reconnect the tendon. If you think you have a significant Achilles injury, seeking medical attention quickly is advised.






There are two general types of Achilles tendon repairs. One is the more traditional open procedure. The second is a minimally invasive procedure that involves a smaller incision. To date, there is no evidence that the minimally invasive procedure has a more positive outcome than the open procedure.

Following Achilles tendon surgery an immobilizer or in some cases a cast will be worn. Depending on the quality of tissue and strength of repair, the foot will be place in some degree of plantar flexion. Often, as healing occurs over the next number of weeks, the amount of plantar flexion will be reduced to help with tissue flexibility.

The length of immobilization and the amount of time crutches will be required will be based on the quality of tissue and the strength of the repair. Many surgeons recommend being immobilized for six to eight weeks following tendon repair. The initiation of Physical therapy may be allowed while the immobilizer is still being used.

Some studies indicate that early weight bearing and early mobilization can improve tissue strength and minimize muscle atrophy. Consult your surgeon regarding his/her protocol regarding how long you will be on crutches or in a walking boot.


Physical Therapy

The physical therapy process following an Achilles tendon rupture and repair can be long. During immobilization, tissues become both stiff and weak. The initial focus of physical therapy will be to reduce swelling, improve mobility of the incision and scar tissue, and restore flexibility.

Utilizing ice therapy and elevation will be helpful in reducing post operative swelling. Progress toward return to walking with full weight bearing with a normal heel to toe pattern will be made as flexibility and strength improve.

An important aspect to consider while you are unable to exercise the involved ankle during the immobilization phase is to exercise the knee and hip to maintain muscle strength. In addition, research indicates that even exercising the uninvolved or opposite leg adds value to the recovery of the injured side.

The ability to regain calf strength and muscle size following an Achilles tendon rupture can take months. The calf muscles are slow to regain size after prolonged immobilization. The good news is that normal calf muscle size is not necessary for a return to full function.

The return to full sports and running activity will take at least four months following tendon surgery.


Summary

• Achilles tendon ruptures occur more frequently in people that have had Achilles tendonitis or a history of Achilles tightness.

• The Thompson test and an MRI will be used to diagnose the tendon rupture.

• Most tendon tears will require surgery.

• Weeks of immobilization may be required following Achilles tendon surgery and a minimum of a few months of physical therapy required to return to full activity.



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References

Curr Rev Musculoskelet Med. 2008 Jun;1(2):161-4.The ruptured Achilles tendon: operative and non-operative treatment options.Metzl JA, Ahmad CS, Levine WN

Hong Kong Med J. 2008 Aug;14(4):255-8.Minimally invasive repair of ruptured Achilles tendon.Chan SK, Chung SC, Ho YF.

Foot Ankle Clin. 2009 Dec;14(4):699-709.Open repair of acute Achilles tendon ruptures.Rosenzweig S, Azar FM.


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